Improving the quality of evidence production in rehabilitation. Results of the 5th Cochrane Rehabilitation Methodological Meeting

The paper introduces the Special Sections of the European Journal of Physical and Rehabilitation Medicine dedicated to the 5th Methodological Meeting of Cochrane Rehabilitation. It introduces Cochrane Rehabilitation; its vision, mission and goals; discusses why the Methodological Meetings were created; and reports on their organisation and previous outcomes. The core content of this editorial is the 5th Methodological Meeting held in Milan in September 2023. The original title for this meeting was "The Rehabilitation Evidence Ecosystem: useful study designs." The focus of the Milan meeting was informed by the lessons learned by Cochrane Rehabilitation in the past few years, by the new rehabilitation definition for research purposes, by the collaboration with the World Health Organization (WHO), and by the REH-COVER (Rehabilitation COVID-19 Evidence-Based Response) action. During the Meeting, participants discussed the current methodological evidence on the following: RCTs in rehabilitation coming from meta-epidemiological studies; observational study designs - specifically the IDEAL Framework (Idea, Development, Exploration, Assessment, Long-term study) and its potential implementation in rehabilitation and the Target Trial Emulation framework: Single Case Experimental Designs; complex intervention studies: health services research studies, and studies using qualitative approaches. The Meeting culminated in the development of a first version of a "road map" to navigate the evidence production in rehabilitation according to the previous discussions. The Special Sections' papers present all topics discussed at the meeting, and a methodological paper about choosing the right research question, presenting final results and the "road map" for evidence production in rehabilitation.

A systematic review that is ``rapid'' and ``living'': A specific answer to the COVID-19 pandemic

OBJECTIVE

This study aims to describe "rapid living" systematic reviews, an innovative methodological design used to systematically synthesize emerging evidence in the field of rehabilitation during the COVID-19 pandemic.

STUDY DESIGN AND SETTING

A methodological paper, with a formative approach to rapid living systematic reviews.

RESULTS

Based on our experience, we propose the following definition of rapid living SR: ``A dynamic method of knowledge synthesis that allows for the constant updating of new emerging evidence and refinement of its methodological quality.'' This method has the benefit of accelerating the conduct of traditional systematic reviews and allows for a synergistic adaptation of methodology based on the quality of the evidence with a flexibility to update results, methods and collaborations.

CONCLUSION

Our proposed methodology has been helpful to synthesize the rapidly evolving evidence in the field of rehabilitation during the pandemic. Similarly, it may be useful when a rapid answer is urgently needed to make informed decisions. The COVID-19 disease has shown that modern medical science has the ability to produce new knowledge at a rate never seen before. Therefore, our proposed rapid living systematic reviews provide the scientific community with a method to rapidly synthesize evidence when facing health emergencies.

Methodological Issues in Rehabilitation Research: A Scoping Review

OBJECTIVE

To identify, synthesize, and categorize the methodological issues faced by the rehabilitation field.

DATA SOURCES

A scoping review was conducted using studies identified in MEDLINE, the Cochrane Library, EMBASE, Web of Science, Scopus, Physiotherapy Evidence Database, and Google Scholar up to August 2018.

STUDY SELECTION

We included all type of publications describing methodological issues in rehabilitation research where rehabilitation is described as a multimodal process. The methodological issues have been categorized and classified.

DATA EXTRACTION

The synthesis included qualitative and quantitative analysis. To focus the attention on rehabilitation, we post hoc divided in "specific issues" (highly related to, even if not exclusive of, rehabilitation research) and "generic issues" (common in biomedical research).

DATA SYNTHESIS

Seventy-one publications were included: 68% were narrative reviews, 15% systematic reviews, 7% editorials, 4% meta-epidemiologic studies, and 5% others. Specific methodological issues include the following: problematic application of randomized controlled trials (32%), absent definition of core outcome sets (28%), poor interventions description (22%), weak methodological (conducting) and reporting quality (21%), scarce clinical practice applicability (14%), lack of blinding assessor (10%), inadequate randomization methods or inadequate allocation concealment (8%), and inadequate participants description and recruitment (8%). "Generic" issues included the following: data and statistical description (31%), authors' methodological training (7%), peer review process (6%, n=4), funding declaration (6%), ethical statement (3%), protocol registration (3%), and conflict of interest declaration (1%).

CONCLUSIONS

Methodological and reporting issues might influence the quality of the evidence produced in rehabilitation research. The next steps to move forward in the field of rehabilitation could be to evaluate the influence of all these issues on the validity of trial results through meta-epidemiologic studies and to develop specific checklists to provide guidance to authors to improve the reporting and conduct of trials in this field.

Systematic Review of Clinical Practice Guidelines for Individuals With Amputation: Identification of Best Evidence for Rehabilitation to Develop the WHO's Package of Interventions for Rehabilitation

OBJECTIVES

To report the results of the systematic search performed to identify interventions and related evidence for rehabilitation of individuals with amputation based on the current evidence from clinical practice guidelines (CPG).

DATA SOURCES

Pubmed, Pedro, CINAHL, Embase, Google Scholar, and multiple guideline databases (date restriction, 2008-2018).

STUDY SELECTION

Exclusion criteria were no CPG, not reporting on rehabilitation, published before 2008, developed for health conditions other than amputation, presence of conflict of interest (financial or nonfinancial), lack of information on the strength of the recommendation, and lack of quality assessed by the "Appraisal of Guidelines for Research and Evaluation."

DATA EXTRACTION

Data extraction was done using a standardized form, which comprised information on the recommendation, the strength of recommendation and the quality of the evidence used to inform the recommendation.

DATA SYNTHESIS

We included 4 guidelines, providing a total of 217 recommendations (20 on assessments, 131 on interventions, and 66 on service provision). Most recommendations concerned pain management, education, pre- and postoperative management, and residual limb care. The strength of recommendation was generally weak to intermediate. The level of evidence mostly compromised expert opinions, with only 6.9% (15 of 217) being provided by randomized controlled trials, systematic reviews, or meta-analyses.

CONCLUSIONS

The field of amputation is well covered for recommended interventions, but the level of evidence is generally low and is based mostly on expert opinion. Some important domains are not covered (eg, vocation and education, sexual and/or intimate relationships, activities of daily living or leisure activities, education concerning socket/liner fitting). There is also a lack of description of the contents of training and rehabilitation programs. This should be taken into account for the development of future guidelines.

The Cochrane Corners by Cochrane Rehabilitation

Cochrane Rehabilitation (CR) is pursuing the goal of disseminating Cochrane evidence, in line with the Cochrane Knowledge Translation (KT) strategy theme 2: "Packaging, push, and support implementation", through several projects: the CR eBook project, blogshots, and Cochrane Corners. A Cochrane Corner is a KT vehicle in which the contents of the Cochrane Library are summarized and presented by a rehabilitation professional, using the qualitative statements proposed by Cochrane Norway to communicate the magnitude of rehabilitation intervention effects on specific outcomes, based on the certainty of evidence, and followed by a section on "clinical implication for rehabilitation professionals" (both for clinical and research practice). Our Cochrane Corners aim to inform about evidence produced by Cochrane in the field of rehabilitation from a rehabilitation professional perspective. After setting internal rules for Cochrane Corners, designing a template and preparing a guide for authors, the production of Cochrane Corners started. As of December 2019, CR signed Publication Agreements with 13 rehabilitation relevant Journals, contributed to Editorials as introductory articles for the launch of Cochrane Corners in some of these Journals and published 34 Cochrane Corners, in print or ahead of print, whereas 7 additional Cochrane Corners have been submitted to the Journals and will be published soon. This initiative provided a significant opportunity for CR to communicate with members of other groups within Cochrane as well as with journal editors. The impact of Cochrane Corners on the readers will need to be evaluated in the future: unfortunately, we have no instruments to measure it at present.

Exercise-based rehabilitation for major non-communicable diseases in low-resource settings: a scoping review

INTRODUCTION

While there is substantial evidence for the benefits of exercise-based rehabilitation in the prevention and management of non-communicable disease (NCD) in high-resource settings, it is not evident that these programmes can be effectively implemented in a low-resource setting (LRS). Correspondingly, it is unclear if similar benefits can be obtained. The objective of this scoping review was to summarise existing studies evaluating exercise-based rehabilitation, rehabilitation intervention characteristics and outcomes conducted in an LRS for patients with one (or more) of the major NCDs.

METHODS

The following databases were searched from inception until October 2018: PubMed/Medline, Embase, CINAHL, Cochrane Library, PsycINFO and trial registries. Studies on exercise-based rehabilitation for patients with cardiovascular disease, diabetes, cancer or chronic respiratory disease conducted in an LRS were included. Data were extracted with respect to study design (eg, type, patient sample, context), rehabilitation characteristics (eg, delivery model, programme adaptations) and included outcome measures.

RESULTS

The search yielded 5930 unique citations of which 60 unique studies were included. Study populations included patients with cardiovascular disease (48.3%), diabetes (28.3%), respiratory disease (21.7%) and cancer (1.7%). Adaptations included transition to predominant patient-driven home-based rehabilitation, training of non-conventional health workers, integration of rehabilitation in community health centres, or triage based on contextual or patient factors. Uptake of adapted rehabilitation models was 54%, retention 78% and adherence 89%. The majority of the outcome measures included were related to body function (65.7%).

CONCLUSIONS

The scope of evidence suggests that adapted exercise-based rehabilitation programmes can be implemented in LRS. However, this scope of evidence originated largely from lower middle-income, urban settings and has mostly been conducted in an academic context which may hamper extrapolation of evidence to other LRS. Cost-benefits, impact on activity limitations and participation restrictions, and subsequent mortality and morbidity are grossly understudied.